1053507822 NPI number — TRADITIONAL FAMILY PRACTICE INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053507822 NPI number — TRADITIONAL FAMILY PRACTICE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRADITIONAL FAMILY PRACTICE INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053507822
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2204 TORRANCE BLVD
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
TORRANCE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90501-2544
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-328-2146
Provider Business Mailing Address Fax Number:
310-328-2242

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2204 TORRANCE BLVD
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
TORRANCE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90501-2544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-328-2146
Provider Business Practice Location Address Fax Number:
310-328-2242
Provider Enumeration Date:
09/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
AFONICHEVA
Authorized Official First Name:
LUDMILA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
310-328-2146

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  W17913 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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